What medications are used to treat anxiety disorders?

Antidepressants, anti-anxiety medications, and beta-blockers are the most common medications used for anxiety disorders.

Anxiety disorders include:

• Obsessive compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Generalized anxiety disorder (GAD)
• Panic disorder
• Social phobia.

Antidepressants

Antidepressants were developed to treat depression, but they also help people with anxiety disorders. SSRIs such as fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa) are commonly prescribed for panic disorder, OCD, PTSD, and social phobia. The SNRI venlafaxine (Effexor) is commonly used to treat GAD. The antidepressant bupropion (Wellbutrin) is also sometimes used. When treating anxiety disorders, antidepressants generally are started at low doses and increased over time.

Some tricyclic antidepressants work well for anxiety. For example, imipramine (Tofranil) is prescribed for panic disorder and GAD. Clomipramine (Anafranil) is used to treat OCD. Tricyclics are also started at low doses and increased over time.

MAOIs are also used for anxiety disorders. Doctors sometimes prescribe phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan). People who take MAOIs must avoid certain food and medicines that can interact with their medicine and cause dangerous increases in blood pressure. For more information, see the section on medications used to treat depression.

Benzodiazepines (anti-anxiety medications)

The anti-anxiety medications called benzodiazepines can start working more quickly than antidepressants. The ones used to treat anxiety disorders include:

• Clonazepam (Klonopin), which is used for social phobia and GAD
• Lorazepam (Ativan), which is used for panic disorder
• Alprazolam (Xanax), which is used for panic disorder and GAD.

Buspirone (Buspar) is an anti-anxiety medication used to treat GAD. Unlike benzodiazepines, however, it takes at least two weeks for buspirone to begin working.

Clonazepam, listed above, is an anticonvulsant medication. See FDA warning on anticonvulsants under the bipolar disorder section.

Beta-blockers

Beta-blockers control some of the physical symptoms of anxiety, such as trembling and sweating. Propranolol (Inderal) is a beta-blocker usually used to treat heart conditions and high blood pressure. The medicine also helps people who have physical problems related to anxiety. For example, when a person with social phobia must face a stressful situation, such as giving a speech, or attending an important meeting, a doctor may prescribe a beta-blocker. Taking the medicine for a short period of time can help the person keep physical symptoms under control.

What are the side effects?

See the section on antidepressants for a discussion on side effects. The most common side effects for benzodiazepines are drowsiness and dizziness. Other possible side effects include:

• Upset stomach
• Blurred vision
• Headache
• Confusion
• Grogginess
• Nightmares.

Possible side effects from buspirone (BuSpar) include:

• Dizziness
• Headaches
• Nausea
• Nervousness
• Lightheadedness
• Excitement
• Trouble sleeping.

Common side effects from beta-blockers include:

• Fatigue
• Cold hands
• Dizziness
• Weakness.

In addition, beta-blockers generally are not recommended for people with asthma or diabetes because they may worsen symptoms.

How should medications for anxiety disorders be taken?

People can build a tolerance to benzodiazepines if they are taken over a long period of time and may need higher and higher doses to get the same effect. Some people may become dependent on them. To avoid these problems, doctors usually prescribe the medication for short periods, a practice that is especially helpful for people who have substance abuse problems or who become dependent on medication easily. If people suddenly stop taking benzodiazepines, they may get withdrawal symptoms, or their anxiety may return. Therefore, they should be tapered off slowly.

Buspirone and beta-blockers are similar. They are usually taken on a short-term basis for anxiety. Both should be tapered off slowly. Talk to the doctor before stopping any anti-anxiety medication.

Reprints:

This publication is in the public domain and may be reproduced or copied without permission from NIMH. We encourage you to reproduce it and use it in your efforts to improve public health. Citation of the National Institute of Mental Health as a source is appreciated. However, using government materials inappropriately can raise legal or ethical concerns, so we ask you to use these guidelines:

• NIMH does not endorse or recommend any commercial products, processes, or services, and our publications may not be used for advertising or endorsement purposes.
• NIMH does not provide specific medical advice or treatment recommendations or referrals; our materials may not be used in a manner that has the appearance of providing such information.
• NIMH requests that non-Federal organizations not alter our publications in ways that will jeopardize the integrity and "brand" when using the publication.
• Addition of non-Federal Government logos and Web site links may not have the appearance of NIMH endorsement of any specific commercial products or services or medical treatments or services.

If you have questions regarding these guidelines and use of NIMH publications, please contact the NIMH Information Center at 1-866-615-6464 or e-mail at nimhinfo@nih.gov.

The photos in this publication are of models and are used for illustrative purposes only.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 08-3929
Revised 2008

What medications are used to treat depression?

Depression is commonly treated with antidepressant medications. Antidepressants work to balance some of the natural chemicals in our brains. These chemicals are called neurotransmitters, and they affect our mood and emotional responses. Antidepressants work on neurotransmitters such as serotonin, norepinephrine, and dopamine.

The most popular types of antidepressants are called selective serotonin reuptake inhibitors (SSRIs). These include:

• Fluoxetine (Prozac)
• Citalopram (Celexa)
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Escitalopram (Lexapro).

Other types of antidepressants are serotonin and norepinephrine reuptake inhibitors (SNRIs). SNRIs are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). Another antidepressant that is commonly used is bupropion (Wellbutrin). Bupropion, which works on the neurotransmitter dopamine, is unique in that it does not fit into any specific drug type.

SSRIs and SNRIs are popular because they do not cause as many side effects as older classes of antidepressants. Older antidepressant medications include tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOIs). For some people, tricyclics, tetracyclics, or MAOIs may be the best medications.

What are the side effects?

Antidepressants may cause mild side effects that usually do not last long. Any unusual reactions or side effects should be reported to a doctor immediately.

The most common side effects associated with SSRIs and SNRIs include:

• Headache, which usually goes away within a few days.
• Nausea (feeling sick to your stomach), which usually goes away within a few days.
• Sleeplessness or drowsiness, which may happen during the first few weeks but then goes away. Sometimes the medication dose needs to be reduced or the time of day it is taken needs to be adjusted to help lessen these side effects.
• Agitation (feeling jittery).
• Sexual problems, which can affect both men and women and may include reduced sex drive, and problems having and enjoying sex.

Tricyclic antidepressants can cause side effects, including:

• Dry mouth.
• Constipation.
• Bladder problems. It may be hard to empty the bladder, or the urine stream may not be as strong as usual. Older men with enlarged prostate conditions may be more affected.
• Sexual problems, which can affect both men and women and may include reduced sex drive, and problems having and enjoying sex.
• Blurred vision, which usually goes away quickly.
• Drowsiness. Usually, antidepressants that make you drowsy are taken at bedtime.

People taking MAOIs need to be careful about the foods they eat and the medicines they take. Foods and medicines that contain high levels of a chemical called tyramine are dangerous for people taking MAOIs. Tyramine is found in some cheeses, wines, and pickles. The chemical is also in some medications, including decongestants and over-the-counter cold medicine.

Mixing MAOIs and tyramine can cause a sharp increase in blood pressure, which can lead to stroke. People taking MAOIs should ask their doctors for a complete list of foods, medicines, and other substances to avoid. An MAOI skin patch has recently been developed and may help reduce some of these risks. A doctor can help a person figure out if a patch or a pill will work for him or her.

How should antidepressants be taken?

People taking antidepressants need to follow their doctors' directions. The medication should be taken in the right dose for the right amount of time. It can take three or four weeks until the medicine takes effect. Some people take the medications for a short time, and some people take them for much longer periods. People with long-term or severe depression may need to take medication for a long time.

Once a person is taking antidepressants, it is important not to stop taking them without the help of a doctor. Sometimes people taking antidepressants feel better and stop taking the medication too soon, and the depression may return. When it is time to stop the medication, the doctor will help the person slowly and safely decrease the dose. It's important to give the body time to adjust to the change. People don't get addicted, or "hooked," on the medications, but stopping them abruptly can cause withdrawal symptoms.

If a medication does not work, it is helpful to be open to trying another one. A study funded by NIMH found that if a person with difficult-to-treat depression did not get better with a first medication, chances of getting better increased when the person tried a new one or added a second medication to his or her treatment. The study was called STAR*D (Sequenced Treatment Alternatives to Relieve Depression).2,3

Are herbal medicines used to treat depression?

The herbal medicine St. John's wort has been used for centuries in many folk and herbal remedies. Today in Europe, it is used widely to treat mild-to-moderate depression. In the United States, it is one of the top-selling botanical products.

The National Institutes of Health conducted a clinical trial to determine the effectiveness of treating adults who have major depression with St. Johns wort. The study included 340 people diagnosed with major depression. One-third of the people took the herbal medicine, one-third took an SSRI, and one-third took a placebo, or "sugar pill." The people did not know what they were taking. The study found that St. John's wort was no more effective than the placebo in treating major depression.4 A study currently in progress is looking at the effectiveness of St. John's wort for treating mild or minor depression.

Other research has shown that St. John's wort can dangerously interact with other medications, including those used to control HIV. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. Also, St. Johns wort may interfere with oral contraceptives.

Because St. John's wort may not mix well with other medications, people should always talk with their doctors before taking it or any herbal supplement.

FDA warning on antidepressants

Antidepressants are safe and popular, but some studies have suggested that they may have unintentional effects, especially in young people. In 2004, the FDA looked at published and unpublished data on trials of antidepressants that involved nearly 4,400 children and adolescents. They found that 4 percent of those taking antidepressants thought about or tried suicide (although no suicides occurred), compared to 2 percent of those receiving placebos (sugar pill).

In 2005, the FDA decided to adopt a "black box" warning label—the most serious type of warning—on all antidepressant medications. The warning says there is an increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24.

The warning also says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor. To find the latest information visit the FDA website.

Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.5 The study was funded in part by NIMH.

Finally, the FDA has warned that combining the newer SSRI or SNRI antidepressants with one of the commonly-used "triptan" medications used to treat migraine headaches could cause a life-threatening illness called "serotonin syndrome." A person with serotonin syndrome may be agitated, have hallucinations (see or hear things that are not real), have a high temperature, or have unusual blood pressure changes. Serotonin syndrome is usually associated with the older antidepressants called MAOIs, but it can happen with the newer antidepressants as well, if they are mixed with the wrong medications.

Reprints:

This publication is in the public domain and may be reproduced or copied without permission from NIMH. We encourage you to reproduce it and use it in your efforts to improve public health. Citation of the National Institute of Mental Health as a source is appreciated. However, using government materials inappropriately can raise legal or ethical concerns, so we ask you to use these guidelines:

• NIMH does not endorse or recommend any commercial products, processes, or services, and our publications may not be used for advertising or endorsement purposes.
• NIMH does not provide specific medical advice or treatment recommendations or referrals; our materials may not be used in a manner that has the appearance of providing such information.
• NIMH requests that non-Federal organizations not alter our publications in ways that will jeopardize the integrity and "brand" when using the publication.
• Addition of non-Federal Government logos and Web site links may not have the appearance of NIMH endorsement of any specific commercial products or services or medical treatments or services.

If you have questions regarding these guidelines and use of NIMH publications, please contact the NIMH Information Center at 1-866-615-6464 or e-mail at nimhinfo@nih.gov.

The photos in this publication are of models and are used for illustrative purposes only.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 08-3929
Revised 2008

I am writing to give you an update regarding your student, who is coping with an Anxiety Condition. Individuals with anxiety are sensitive and may be easily triggered to feel unsafe. The good news, is that many things that can be done to help those with anxiety feel safer. When students with anxiety can participate in the school environment, they can bring an incredible sense of empathy, sensitivity and kindness to the environment that benefits everyone. 

• Meet with the student and family to talk about the student's needs.
  • Develop a coping plan, which include:

    • Student’s strengths

    • Potential problems, stresses or issues

    • Strategies and solutions to try

  • Self-regulation programs such as "Zones of Regulation" can be helpful.
     
• Make efforts to connect to the student such as: 

  • Having check-ins at the beginning of the day when the student arrives.
  • Understand that the student may arrive late, without being critical or blaming of this. 
  • Accepting and validating the student’s anxiety, e.g. “I wonder if you’re feeling anxious… I appreciate it can’t be easy.”

  • Don’t invalidate the anxiety, e.g. don’t say: “That’s a silly thing to be worried about.” 

  • Showing an interest in the student, e.g. spending time to get to know the student, his/her hopes and dreams, interests, strengths, etc. 
     
• Has the student had a stressful incident? After the student has calmed down, try to find a time to meet with the student / parents and problem-solve. What were the triggers? What might help next time?


Recommendations for the Daily Schedule 

• Allow breaks as needed in a designated “chill out space”. Some students may need regular breaks as a preventive measure for stress buildup.  Ensure that there are also opportunities for the student to let you know when things are stressful, and then the student can have a break as needed (i.e., break card). The “chill out space” is a space in a calmer (i.e. less sensory input), relatively private place at school where the student can use different coping strategies until the student is feeling calmer. Examples vary depending on the student and the school, but may include a corner in the classroom; resource room where there are less students; the library.




• 


Does the student have sensory issues or needs? E.g. fidgets for tactile stimulation/distraction; hearing protectors for sensitivity to loud noises, etc.

Workload accommodations 

• Set clear expectations and try to check if the student understands. Some students have anxiety because they want to please the teacher, yet they are uncertain about their teacher’s expectations, but are too anxious to let the teacher know that they don’t understand.
   
• Chunk work. Be prepared to “chunk” larger work into smaller manageable pieces and provide ongoing feedback, or offers to help.



   
• Expose the student to challenges step by step. For example, with performance anxiety, the student can initially present material only to the teacher or in small groups. If the student is successful with this, they can move towards presenting to larger and larger numbers of students, until it is the full class.



   
• For older students, a reduced course load may be needed.  The possibility of a resource period, or learning skills course, should be explored.

• Is the student having troubles following a teacher's instruction in the classroom? Look beyond the behaviour, and explore why the student is unable to follow the instruction. Most likely, the student is not being 'oppositional', but likely struggling. Students do well if they can.
  
• Don’t put him/her on the spot by calling on them to answer a question in front of the class. Even though the student may be perfectly capable of answering a question, the student may still be anxious with being the centre of attention.


   
• Allow the student to choose a partner during group work and, when possible, allow him/her to work only with one partner (as opposed to a larger group).
• Consider having a classroom lesson about anxiety, and ways of coping, which helps all students be more understanding with anxiety. Do not single out students with anxiety by mentioning their names, but rather make the lesson about anxiety in general.



   
• Model self-compassion. For many students, anxiety is about feeling unsafe due to not measuring up to expectations around them. Teach self-compassion by ensuring that the classroom models the following:

  • Mindfulness: Teach students how to be in the moment, rather than distracted.

  • Kindness and compassion to others: Have a classroom that values kindness over competition.

  • Kindness and compassion to ourselves: When you hear students being self-critical, reframe the criticism in a positive and forgiving manner.



  • Gratitude: Consider incorporating gratitude into school routines, such as at the end of the classroom day.



     
• Stop stigma and teasing. Deal immediately with any negative behavior by peers towards more sensitive students.


Testing Accommodations

• For tests and exams, consider a separate testing room and extra time if needed.




• Building Resilient Students with Positive Mental Health
  
http://smh-assist.ca/blog/2016/03/15/building-resilient-students-with-positive-mental-health-flip-book-cdsbeo/ 



   
• Supporting Minds
  
https://www.edu.gov.on.ca/eng/document/reports/SupportingMinds.pdf


I am writing to give you an update regarding your student, who having Mood Problems, i.e. Depression.   

Accommodations are essential for this student to function in the academic program. Feel free to adapt this list, however, here is a general list of suggested accommodations.

Instructional Strategies

Interpersonal interventions

• Feeling connected to people is particularly important with mood problems, particularly because students with mood problems youth tend to withdraw from others. Help connect the student to supportive peers, and offer opportunities to participate in organized school activities such as clubs, sports.
• Make a special contact with the student each day. Maybe a specific greeting at the door followed by a question about something that has been of interest to the student.

Build strength and resiliency by reinforcing successes and positives

• What times has your student been successful at things in the past? What are your student’s strengths? Tell the student about any positives.
• Being successful and accomplishing tasks increases self-esteem so find ways to ensure the student has chances to achieve, even at his/her lower energy level and reduced ability to concentrate.

Reduce workload

• Mood problems such as depression may lower the student’s ability to work. Consider temporarily reducing the academic expectations and workload. Just like one might modify job tasks for a worker with back injury, it is important to modify tasks for a student with mood problems.

Give more time

• Students with mood problems tend to have problems with attention and concentration. Give more time, break assignments into smaller pieces, offer extra help in setting up schedules or study habits, or pair the student with others who express an interest in helping.

Coping / Stress Breaks (aka ‘Chill Time’) (Try to avoid the term ‘Time Out’ because for some students this has a negative connotation…)

• Expressing stress  -- Come up with a system to help the student identify when s/he is getting overwhelmed, and be able to communicate that to the teachers.
• For example, using a 5-point scale, where 1 is no problems, and 5 is being stressed and overwhelmed

Create a safe space

• Designate a “chill out zone” / “safe place” where the student can go if s/he is feeling overwhelmed. By giving the student the ability to calm down at school, this will lessen the chances that the student will end up leaving the school.
• Talk ahead of time privately with the student, and set up some signal or cue so that the student can leave the class if the student is getting overwhelmed.

Set clear expectations

• Many students have anxiety because they are uncertain about their teacher’s expectations. To help with this, provide the student with explicit guidelines for assignments. In addition, explicit guidelines for assignments help mitigate the negative impact of anxiety and depression symptoms on executive functioning. (Executive skills help a student to regulate his or her behavior. Through the use of these skills a student can plan and organize activities, sustain attention, and persist to complete a task.)

Classroom Education / Anti-Stigma

• Consider having a lesson about mood problems, in order for other students to know about anxiety so that they can understand what the student with mood problems is going through. Do not single out the student with mood problems, but make the lesson a about mood problems in general. For more information, the CMHA has an excellent curriculum here www.cmha.ca/highschoolcurriculum/
• Prevent stigma / teasing: Deal immediately with any negative behavior by peers toward this student
• Provide copies of classroom notes to cover absences due to anxiety, as the student may be missing classes due to anxiety, or doctor’s appointments.

Coping Plan

• Involve the student in coming up with a coping plan, whose elements might include:
• Student’s strengths
• Potential problems or issues
• Strategies and solutions to try

Suicidal ideation and crises

• Although depression does get better in the vast majority of situations, youth with mood problems may become overwhelmed to the point where they may feel passively suicidal (“Life isn’t worth living”), or actively suicidal (“Life isn’t worth living, and I’m going to do something to end my life.”)
• Learn about local resources (i.e. where you might get professional help) in case there are concerns about suicidality. Most likely, your school board already has a policy and procedure in place for such urgent situations.

Examples of Common Workplace Accommodations

Accommodations should be based on your needs and the employer’s resources. There is no standard list of reasonable accommodations, but here is a list of commonly provided workplace accommodations:

• Job coach assistance in hiring and on the job mentoring as necessary. Job coach/mentor could be from an external agency or be from within the organization.

• Flexible scheduling to accommodate effects of medications, time for appointments, more frequent breaks, switch to temporary part-time hours without fear of losing job.

• Changes in supervision, for example how feedback and instruction are given, or having weekly supervision appointments to check in and prevent problems before they can happen.

• In training, allowing more time for tasks to be learned, or allowing for individualized, one-on-one training.

• Appropriate technology like a tape recorder to tape instructions, head phones to block out loud noise, etc.

• Modifying work space or changing location so it is quieter, fewer distractions; allowing an employee to work at home.

• Allowing an employee to exchange minor job tasks with others.

Rights and Responsibilities of the Employer & Employee

The Employer Should:

• Create and maintain an atmosphere where people feel comfortable asking for accommodation, including providing information about the organization’s policies and creating ways for requests to happen confidentially.

• Assume that the employee’s request for accommodation is made in good faith.

• In a timely manner, work with the employee (and a professional, if necessary), to explore all options for accommodation.

• Maintain records of the request and steps taken to deal with the request.

• Maintain and respect confidentiality issues.

• Pay the cost of the accommodations, including fees for any medical certificates required.

• Request only information that is directly related to developing an appropriate accommodation.

• Ensure that managers and supervisory staff will not tolerate any discrimination or harassment as a result of an illness or an accommodation.

The Employee Should

• Tell the employer you need an accommodation, due to a disability, and give them the information they need to understand what the limitations are and what accommodations would address them.

• If requested, provide supporting documentation or medical certificates.

• Meet all relevant job requirements and standards once the accommodation has been provided.

• Continue to work with the employer to ensure that the accommodation remains effective and to check in with how you are doing.

SOURCE

Adapted from “Employment” , in “From Rollercoaster to Recovery”.

ADDITIONAL INFORMATION

• The Alberta Human Rights Commission has additional information on responsibilities for employers around employees with addictions issues
  http://www.albertahumanrights.ab.ca/publications/bulletins_sheets_booklets/ sheets/protected_grounds/drug_and_alcohol_dependencies.asp